I have recently been teaching my nursing students about Evidence Based Practice, Hierarchies of Evidence and the panoply of research methodology. Along with this we tell our students that their Care Plans should be SMART- Specific, Measurable, Achievable, Relevant and Timely. Equipped with these ideas we send our students out into the world of mental health nursing, confident that they have a rational template to help them help their patients. Their confidence is shaken when they have a conversation with a delusional patient who occupies a world of metaphors, similes, fractured and tangental associations. Who will be telling them that the radio is saying that they are responsible for an aeroplane crash; that unseen voices are telling them to rape a woman; the list is long. These students carry on their shift, shaken but confident that what we have taught them will provide a lifeline of sanity. (Whose sanity we will not ask!) They might risk talking their mentor about this experience. Mostly they Facebook each other in the small hours, hoping to find some way of managing their experience. Some will risk staying with their uncertainty but the majority retreat to an ordered world of giving drugs to assuage the patients’ distress. (It was the psychotherapist Tom Main who commented “When the nurse has a headache, the patient gets a pill.”)
Donald Rumsfeld was much mocked for his Known Unknowns speech but it seemed to me at the time-and still does-to be a very wise speech. In the world of psychiatric nursing, counselling and psychotherapy, we constantly work with all Rumsfeld’s categories. The art of good clinical care is to allow ourselves to stay with our anxiety and not rush to find “certainty”. This fantasy about certainty is my reservation about CBT and any manualised therapy. It assumes a mechanistic view of the psyche. “If I do X, then Y will follow.” I worked with some psychology graduates who were part of a CBT team. They were literally reading the chapter on Negative Automatic Thoughts the evening before seeing a depressed patient the next day. They were fine until the patient deviated from the script they had learned. Then they found themselves facing Unknown Unknowns– which the manual had neglected to mention!
I write this not to mock CBT ,which has its place as a useful therapeutic intervention. Rather I want to highlight the need for we clinicians to be able to tolerate not-knowing. And to know that not-knowing is acceptable. There are two distinctive theological schools of thought that reflect this Knowing / Not Knowing division and have something useful to say to all of us involved in “soul making”. One school of thought is the Triumphalist strain expressed well in the line “God is working His purpose out / As year succeeds to year.” There is a divine Master plan which we are following and which God has drawn up for us. (A Divine Personal Development Plan.) Whatever happens in my life is part of God’s plan for me. Another strand- Process Theology-might be summed up in the line “O sacred head surrounded, by crown of piercing thorns.” In this model God suffers with us and is thinking with us to help us find our way together. The latter model is both easier and harder. It makes a better clinical model. I am not the omnipotent therapist who has all the answers. I am a fellow traveller who may be more familiar than you are with the ground we are walking across. I can point out possible dangers. And help you think about where you are and where you might want to reach. But the journey costs me as well. It is the difference between the Wounded Healer and the impregnable Super Hero.
And here is a link to that famous reply by Rumsfeld